F.A. Davis Company

Build your documentation skills—and your confidence. Step by step, this text/workbook introduces you to the importance of documentation and shows you how to develop and write a proper and defensible note.

You’ll learn how to provide the proper documentation to assure all forms of reimbursement (including third party) for your services. You’ll also explore issues of patient confidentiality, HIPAA requirements, and the ever-increasing demands of legal and ethical practice in a litigious society.

• Review questions and practice exercises help you assess your understanding of all aspects of SOAP notes.
• Examples of appropriate and inappropriate notes show what and what not to do.
• Examples of different types of documentation and forms illustrate procedures in multiple practice settings.
• All the terminology adheres to the upcoming and newly revised APTA’s Guide to Physical Therapy Practice.

1. Why is Documentation Important?
   1. Introduction to Documentation?
   2. The World Health Organization and the International Classification of Functioning, Disability and Health
   3. Reimbursement Issues Related to Documentation
   4. Documentation Content and Organization
   5. Physical Therapy Patient Management and Documentation Responsibilities
2. Steps to Documentation
   6. Introduction to the SOAP Note
   7. What Is Subjective Data and Why Is It Important?
   8. What Is Objective Data and Why Is It Important?
   9. What Is Assessment Data and Why Is It Important?
   10. What Is the Plan and Why Is It Important?
   11. Putting the Pieces of the Puzzle Together
3. How Do SOAP Notes Ensure Good Patient Care?
   12. How Does Documentation Relate to Patient Issues?
   13. Your Documentation Related to Legal and Ethical Issues
4. Testing What You Know
   14. Do You Know Enough?

• NEW! Two new chapters, Reimbursement Issues Related to Documentation and The World Health Organization and the International Classification of Functioning, Disability and Health, that help you make sense out of new requirements and understand the ICF Model’s effects on PTA’s and ICD Coding System and patient care.
• EXPANDED! Coverage of electronic documentation.
• EXPANDED! Additional information and more practice exercises in multiple chapters.